OAMPS Sports Risk Management Basketball Australia Insurance CLAIM FORM
Sports Insurance Claim Form 1. Please complete Parts 1,2,3,4,5,6,7 and 8 of this claim form (pages 2 and 3), plus the injury data collection questions on pages 5 and 6 2. Ask Your doctor to complete the Medical Statement (pages 7 and 8) 3. If Your claim is for loss of earnings: (a) Ask Your employer to complete Part 9 (page 4). If You are self-employed please have Your accountant complete these details (b) Forward a medical certificate every two weeks if Your disability is continuing 4. An authorised official of Your club must complete Part 10 (page 4) 5. Please refer to Notes for claimants on page 9 The Association 1 Sport played Regional body Association name Club Team Age group Grade Seniors Reserves (if applicable) The Member 2 Name Address Phone Work Mobile Email Address Occupation Date of Birth....... /....... /....... Sex: Male Female Registration number (If Known) Details of the Member s Disability or Injury 3 What is the nature of Your injury? What body part/s has been injured? Is it a recurrence of a previous injury? Yes No How did it happen? Where were You when it happened? Type of location Sportsground Gymnasium Swimming pool If please describe When did the injury occur? Date:....... /....... /....... Time: What were You doing? Playing a match Warm up Training sport Gradual onset What was the event? Competition Regular training Training camp Private training If please describe OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 2
Details of the Member s treatment 4 Name and address of each hospital You attended Name, address and phone numbers of all attending doctors Date of Admission:....... /....... /....... Discharge:....... /....... /....... Name, address and phone number of Your usual doctor Details of the Member s previous Disabilities, injuries or claims 5 Were You suffering any previous medical condition? Yes No If Yes, give details of the condition Have You ever made a claim under a sports injury or personal accident insurance policy? Yes No If Yes, what was the date of injury Who was the insurer? How much were You paid? What was the injury? Name and address of the doctor....... /....... /....... Details of the Member s insurance 6 Are You a member of a health fund Yes No If Yes, what type of membership do You have? Hospital cover only Ancilliary cover only Hospital plus ancilliary benefits Name of health fund Membership number Any other details regarding private health cover Do You have any other insurance to cover this disability or Injury? Yes No If Yes, please show name and address of insurer Drugs and intoxicating liquor 7 Were You under the influence of any drug or intoxicating liquor when the disability or injury took place Yes No If Yes, please give details Have You taken any performance enhancing drugs? Yes No The Member s declaration 8 By signing this claim form I declare that Must be completed by the injured Member or their guardian if the member is under 18 years a. All the information that I have given in this form is correct b. I authorise any doctor, hospital or other person who has treated me to provide OAMPS Insurance Brokers Ltd. or its representative with any medical records for any illness or injury I have suffered. c. I authorise my employer to provide OAMPS Insurance Brokers Ltd. or its representative with details of my salary and working hours. d. I agree that a photocopy of this authorisation will be accepted as valid. e. I agree to allow the insurer to ask or tell other insurers or insurance reference bureaux about this or any other claim I have made. Signature Date....... /....... /....... OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 3
The Member s employment details (Must be completed by pay clerk/paymaster) 9 Employer s name Employer s address Phone number What was your employee s gross weekly income at the date of injury for the 12 calendar months immediately preceding injury. (excluding bonuses, commissions, overtime or any other allowances) $ p.w. Date You expect Your employee to resume work....... /....... /....... Date You expect Your employee to resume normal duties (fully fit)....... /....... /....... What is Your employee s gross annual salary? What date did he or she commence employment? If self-employed please attach proof of income over the past 12 calendar months immediately preceding injury (net of business expenses, but before income tax and personal deductions e.g. Tax Return). $....... /....... /....... What is the name of Your pay clerk? What is Your pay clerk s phone number? Signature of pay clerk / paymaster Date The Club s declaration 10 Must be completed by the club Secretary or Treasurer If the Player was injured participating in a game please attached a copy of the team sheet to this claim form....... /....... /....... I... Secretary or Treasurer of... Name of club and association Confirm that... Member s name Sustained the injuries resulting in this claim on State Association/OAMPS Office Use Only Player Registration Number... Signed... Position... State Association Stamp Where Applicable... at... Date time While playing or training for... Team against... Opposition Team or while taking part in... Activity against... Opposition Team at... Place of game or activity The first consultation with a doctor for this injury was on... Date at... Address of doctor Signature Club mailing address Date....... /....... /....... Phone number OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 4
Injury data collection OAMPS Insurance Brokers Ltd is committed to Safer Sport. Analysis of sporting injuries is critical to implementing injury prevention strategies. OAMPS Insurance Brokers Ltd, in association with your sport and with your cooperation, is being proactive in collecting injury data with the aim of decreasing injuries. Thank you for assisting with this project. What was Your role at the time of Your injury? Participant Coach Umpire/Referee If other, please provide details How far into the activity were You at the time of the injury? Official Voluntary Worker Spectator Warm up (Note: Your answer relates to the time into the activity, 1st Quarter 2nd Quarter rather than the period/stage of the game) 3rd Quarter 4th Quarter Cool Down On what surface were You participating? Grass Synthetic Surface Wooden Floor Gravel Concrete/Bitumen What was the condition of the surface? Normal Hard Wet Muddy What were the weather conditions as the time of injury? Fine Light Rain Heavy Rain What were the temperature conditions as the time of injury? Very Hot Hot Hot & Humid Mild Cold Very Cold How was the onset of injury? Sudden Gradual If a collision injury, what did You collide with? What was Your activity leading to the injury? Was protective equipment, tape or support being worn on the injury site? If yes, please provide details If protective equipment, please provide details If other support, please provide details How did the injury severity affect Your playing? Started Play With Pre-Existing Injury Ground Equipment Player Structure Landing Jumping Twist/Turn Side Stepping Starting Stopping Running Applying Tackle Being Tackled Receiving Ball Passing/Throwing Hitting Kicking Scrum Ruck Yes Maul No Taping Protective Equip. Support Unable to Continue Playing Continued to Play After Treatment Continued to Play Without Treatment What was the immediate treatment? (more than one box may be ticked) If please provide details Was a sports trainer present at the game? Rest Ice Compression Elevation Stretching Mobilisation Taping Bandaging Sling Splint Unknown Yes No Unknown OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 5
If Your injury required referral, to whom were You referred? Hospital Doctor Physiotherapist Dentist If please provide details If immediate off site treatment was necessary, Ambulance Private Vehicle What mode of transport was used? Please indicate the site of your injury on The appropriate diagram below OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 6
Medical statement This form must be completed by the registered medical doctor treating the injury The Association and Club Association name Club name Type of sport The Member Name Address Age Gender The injury Complete Diagnosis History When did the present disability or injury occur? Date the player ceased work....... /....... /....... Is there a history of the same or similar condition? Is this a recurrence? Yes No Present condition Subjective symptoms Objective finding (give reports of any x-rays, ECGs or other tests) Is the player Walking Bed confined House confined Treatment of present condition Hospital confined Date of admission:....... /....... /....... Progress Date of first consultation....... /....... /....... Date of latest consultation....... /....... /....... Frequency of consultations Date of last hospitalisation....... /....... /....... Name of hospital Nature of surgical procedure Contemplated If performed Date:....... /....... /....... Has condition improved? Yes No If No, please explain Performed OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 7
Degree of disability Has the patient been able to do any work? If No, from what date Regular work:....... /....... /....... Light duties:....... /....... /....... When will the patient be able to resume for Regular work:....... /....... /....... Light duties:....... /....... /....... treatment If the patient was seen in consultation by another doctor,....... /....... /....... please give the date, name and address of that doctor. If the patient is no longer under your care, What date were your services terminated?....... /....... /....... conditions Describe any other disease or infirmity Affecting the patient s present condition Cardiac-circulatory Visual Blood pressure Circulatory disorder please describe Please complete the appropriate section if the disability or injury is due to: Is the patient totally or industrially blind? Yes No If No, what was the vision at last observation With glasses: Distant Near Date:... /... /... What is the extent of any gross visual field defect? Without glasses: Distant Near Date:... /... /... Could vision be improved by treatment, surgery or lenses? Yes No What are the rehabilitation prospects? Orthopedic Please report findings of specialist if referred? Neurological Please report findings of specialist if referred? Prognosis Remarks Please apply doctors name stamp below Signature Date....... /....... /....... Degree Name of Doctor (please print) Address OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 8
Notes for claimants To ensure your claim is processed quickly and efficiently please follow steps below. Please read thoroughly and keep for your own reference Non Medicare medical expenses claim 1. Please note that due to Federal Government Legislation (Sec126, Health Insurance Act 1973) General Insurers are unable to provide benefits on any Medicare related expenses, including gap payments. 2. Refer to instructions on page 2 of claim form. 3. Claims for treatment given by a chiropractor, masseur, naturopath, osteopath or physiotherapist must be accompanied by a referral from a registered medical doctor. 4. If you hold private health insurance you are required to claim all expenses from your private health fund first. Once you have claimed from your health fund please forward your Statement of Benefits Paid, the account and receipt to us. 5. If you have already incurred non-medicare medical expenses, please attach the original tax invoices along with a receipt confirming the account has been paid. Loss of income claim 1. Refer to instructions on page 2 of claim form. 2. If you are self-employed have your accountant complete The Member s Employment Details and supply us with a copy of your last tax assessment. 3. If you are an employee please forward payslips for the four weeks preceding your injury, or a letter from your employer on company letterhead confirming the gross amount earned per week for the four weeks preceding your injury. 4. Loss of income payments will not be made until the Medical Statement, medical certificates and proof of earnings are received. Important 1. Your claim cannot be processed if the claim forms are incomplete or illegible. To ensure your claim is processed without delay please make certain all sections on the Sports Injury Claim Form, Medical Statement, Injury Data Collection questionnaire and any applicable Addendums to Injury Data Collection questionnaires are fully complete 2. Please forward your completed Sports Injury Claim Form to our office within 30 days of your injury. Do no wait for all your medical accounts. Forward them to us as you receive them. 3. Your Personal Accident Sports insurance policy covers medical expenses incurred within 365 days of the date of the event that caused the injury. If you have any questions or problems please contact us, we are always ready to help. If you are dissatisfied with a product or service provided by your Adviser, please contact the Manager of the Branch in your State. If the Branch Manager is unable to resolve the complaint to your satisfaction, you may ask that the matter be referred to the National Complaints Manager for OAMPS Insurance Brokers Ltd. The National Complaints Manager will acknowledge your complaint in writing and endeavour to resolve your problem within 20 working days. Complaints and disputes If you remain dissatisfied, you have the right to refer to your complaint to the Insurance Brokers Disputes Ltd. (IBD). Each of the licenced entities subscribes to the external facility for the handling of complaints. You can refer your complaint to an IBD Case Manager who will conciliate with a view to seeking a solution that is acceptable to both parties. If either you or OAMPS reject the IBD Case Manager s finding and the dispute remains unresolved, it will be referred to the IBD s Referee whose decision is binding on us (but not on you). Further information about the IBD is available for all OAMPS Insurance Brokers Lid offices. Claims Handling Claims are processed at OAMPS Brisbane office (refer address below). To maximise claims handling efficiency send your completed claim form and documentation direct to that office. OAMPS Capital City Offices Adelaide Brisbane Canberra Darwin 168 Greenhill Road Parkside, Adelaide, SA 5063 T: (08) 8172 8000 F: (08) 8172 8100 Lvl 2, 8 Gardner Close Milton, Brisbane, QLD 4064 T: (07) 3367 5000 F: (07) 3367 5100 Ground Floor, 10 Geils Court Deakin ACT 2600 T: (02) 6283 6555 F: (02) 6283 6556 Lvl 2, 71 Smith Street Darwin, NT 0801 T: (08) 8942 5000 F: (08) 8942 5050 Hobart Melbourne Perth Sydney Lvl 4, 85 Macquarie Street Hobart, TAS 7000 T: (03) 6235 1222 F: (03) 6235 1221 289 Wellington Parade South East Melbourne, VIC 3002 T: (03) 9412 1555 F: (03) 9412 1666 Lvl 1, 21 Teddington Street Burswood, WA 6100 T: (08) 6250 8300 F: (08) 6250 8400 Lvl 4, 2-12 Macquarie Street Parramatta, NSW 2150 T: (02) 8838 5700 F: (02) 8838 5701 OAMPS Insurance Brokers Ltd ABN 34 005 543 920 Sports Insurance Claim Form 0481-11SEP09 9